Applying the paradox of prevention: eradicate HIV

The HIV pandemic need never have happened. There is nothing inherent in the virus that made its transition from minor problem to global pandemic inevitable. The virus is relatively weak, not contagious and spreads slowly in human populations. The appalling truth is that the major driver of the spread of HIV was the failure of political will to translate scientific evidence into effective containment policies.

Within a few years of its first notification in the West in the early 1980s, medical science conclusively identified the nature and properties of the virus, devised workable - if not infallible - tests for its presence, and developed the first promising treatments for prolonging the lives of those infected.

In the turbulent wake of the first explosion of cases, a thousand flowers of responses bloomed around the world. They ranged from executions of HIV-positive people, to repressive sanctions, quarantine and denial, through to mass education, and practical and evidence-based policies based on prevention.

Many governments were, and remain, reluctant to offend deeply held social, cultural and religious beliefs about sexual behaviour, drug consumption and sex work, especially among the young. Nevertheless by the end of the 1980s, it was possible to judge all of these responses and determine which had worked best to get new infection rates to sustainable, low levels.

These outcomes were reported at the time to a plethora of international conferences, in specialised journals, government reports and the media. By the end of the 1980s, all of the information and evidence about HIV-AIDS needed to bring the incipient global pandemic under control and long-term management was available. The feasibility of preventing its spread had been demonstrated in Australia and The Netherlands and in large developing countries like Thailand.

The emergence of effective treatments gave hope and incentive to those who might have been reluctant to come forward for HIV testing. The technologies that were crucial if prevention were to be sustained were cheap, and able to be widely and quickly distributed.

By 1990, the global caseload was only about eight million, most in sub-Saharan Africa. Large areas of the globe, including most of the Asia-Pacific region (apart from Thailand) and Central Asia had been scarcely affected. There was, in short, a critical window over a decade from 1985 in which decisive preventive action could almost certainly have contained the global spread of the disease.

The peer-reviewed evidence in favour of behavioural prevention was abundant and well reported at innumerable conferences, meetings and in scholarly journals. At all levels, credible experts pushed for major countries and the international agencies nominally responsible for dealing with HIV-AIDS to adopt rational and pragmatic harm-reduction policies.

The consequences of not acting to prevent the spread of HIV were clearly known and accurately predicted, yet those who should have responded did not do so. The failure of national governments and international agencies to act in time to avert the HIV-AIDS pandemic is both shameful and enraging.

In the 20th century, the world witnessed many examples of governments and politicians steadfastly failing to act in time to avert mass murder, death and destruction. Credible warnings were issued and ignored about the Holocaust, Stalinist Russia, Pol Pot’s Cambodia, the Balkan Wars and the Rwandan genocide. The failure to intervene in time to prevent these tragedies cost millions of lives.

But, in its scale and scope, the global failure to contain HIV-AIDS has caused more deaths and suffering than even the worst of these appalling episodes.

Those who naively declared “war” on HIV-AIDS in the 1980s very rapidly came into conflict with the aims and objectives of two other “wars” - the “war on drugs” and the “war on sex”.